A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Assess the client's ability to communicate with the other staff members.

Arrange a meeting with the family to discuss the client's situation.

Administer the client's antidepressant medication as prescribed.

Establish a structured routine for the client to follow.

Answer and Explanation

The Correct Answer is D

Choice A reason: Assessing communication ability is important but secondary to establishing a structured routine to address the client's immediate needs.

Choice B reason: Arranging a meeting with the family can provide support but is not the first priority in managing the client's depressive symptoms.

Choice C reason: Administering antidepressant medication is essential but must be part of an overall structured plan.

Choice D reason: Establishing a structured routine helps provide stability, encourages participation in daily activities, and addresses the client's refusal to eat and bathe.

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Correct Answer is C

Explanation

Choice A reason: Severe motor dysfunction does influence the extent of successful habilitation, but it does not fully answer the mother’s concern regarding the progression of CP. The focus should be on reassuring the mother about the non-progressive nature of CP.

Choice B reason: The development of the brain lesion is already established in CP and does not continue to develop; thus, it does not determine the child's future outcome. The brain lesion's presence from birth does not change over time.

Choice C reason: Brain damage associated with CP is non-progressive, meaning it does not worsen over time. However, the symptoms and functional impairments can vary and fluctuate, which might make it seem as though the condition is changing.

Choice D reason: While it’s true that CP is one of the most common permanent physical disabilities in children, it doesn’t provide specific information about the progression of the disease. The mother needs to understand that the brain damage itself is not progressive.

A. Ear pain and fever. B. Elevated WBC and sedimentation rate. C. Positive Epstein-Barr, and malaise. D. Increased BUN and serum creatinine.

Correct Answer is C

Explanation

Choice A reason: Ear pain and fever are not specific symptoms of mononucleosis and may indicate other infections such as otitis media.

Choice B reason: Elevated WBC (white blood cell) count and sedimentation rate can be seen in many infections and inflammatory conditions, but they are not specifically diagnostic of mononucleosis.

Choice C reason: Mononucleosis, often caused by the Epstein-Barr virus (EBV), typically presents with a positive EBV test and malaise (general feeling of discomfort or illness). Other common symptoms include fever, sore throat, swollen lymph nodes, and fatigue.

Choice D reason: Increased BUN (blood urea nitrogen) and serum creatinine levels are indicators of kidney function and are not typically associated with mononucleosis.

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A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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